Healthcare Provider Details

I. General information

NPI: 1427130822
Provider Name (Legal Business Name): THERESA RICHARDSON PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/19/2006
Last Update Date: 05/15/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

140 CANAL VIEW BLVD SUITE 102
ROCHESTER NY
14623-2808
US

IV. Provider business mailing address

140 CANAL VIEW BLVD SUITE 102
ROCHESTER NY
14623-2808
US

V. Phone/Fax

Practice location:
  • Phone: 585-338-2700
  • Fax: 585-242-9663
Mailing address:
  • Phone: 585-338-2700
  • Fax: 585-242-9663

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number004950
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number4950
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number004950
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: